Aetna BMI Question - Afraid I Know the Answer

Hello all, this is my very first OH post!  In fact, I'm not sure I'm doing it right. I'm interested in the Lap Band.  I've been to one seminar and I'm scheduled for another on Thursday.  I have not spoken to a surgeon yet.  I have Aetna and they cover the Band with the usual Aetna criteria.  Two years ago, in 2007, we moved cross country NY to MS and I only went to a doctor who weighed me once that whole year - in December, to my new OBGYN.  I had managed to lose about 25 pounds (didn't last, like usual) in the move and I was 186 at that appointment.  I was so happy at the time but now it's come back to haunt me! I'm 5' 3" tall so that makes my BMI 32.9 at that time.  I gained it all back to my more usual ~215 pounds and BMI 38.  I have high blood pressure (153/98) and high cholesterol (220).  My doctor recorded weights are 186 in 12/2007, 202 in 11/2008, and 211 on 2/10/09.  I'm still gaining.  How bad did that short lived weight loss affect my chances at insurance approval?  Don't they require a BMI above 35 for the entire 2 years?  My numbers are all in the obese category (30+).  Aetna's Clinical Policy Bulletin states "Presence of severe obesity that has persisted for at least the last 2 years defined as....a BMI greater than 35 in conjunction with any of the following severe co-morbidities..."  So that pretty much shoots me down doesn't it?  I'll have to go with 2 years from the 202 weight, which means I'm not eligible until November 2010?  Oh. My. Gosh.  I can't beleive I did this.

Think--do you have ANY other recorded weights from that year? Did you attend a weight loss group (WW, TOPS, etc.) where they recorded weight? a gym? a trip to the ER? anything at all where you may have been weighed?

Hi, Jillybean - Thank you for your help! I've been wracking my brains!  We were selling one house, house hunting, switching schools, 2 new jobs, finding a temp apartment, then buying....I just didn't go to the doctor.  I was going to the gym but was never weighed there.  I went to WW but I threw out the weigh in books during all the moves!!  I called WW and they couldn't give me any documentation.  I don't have any qualifying weights in 2006 either. 

Sigh...it's my own fault.  I'm such a yo-yoer, always hovered around 200 and if I was over 200 I wouldn't go to the doctor.  I figured I'd yo-yo down eventually and then go.  And 200 happens to be the exact weight that puts my BMI at 35 ARRGH.  What happened was that in 2001 I was required to have an employment physical.  I was 220.  The doctor had me stand in my bra and panties and made me do a kind of squat on the floor.  Then she walked around me, poking me, and made remarks about my fat.  She kept saying, look how big you are.  You are so big.  After that I just couldn't go to a doctor over 200 for a long time.  I never told anyone that, not even my husband.  I did this to myself!  I'm qualified but I can't prove it.  Let me be a lesson to anyone out there with similar stats.  If you hover right near the line you need that documentation!!  Go get it!!

Unless I have a breakthru of some kind I'll have to start fresh.  I called my new PCP and my first documented  weight was 202 on December 4, 2008 (not November like I thought).  So I'll wait 18 mos, see a surgeon, and then start my 6 mos diet, then go for approval in December 2010.

you could try to use the 12/2007 weight as proof that you are continuing to gain weight and try it this year... nothing really to loose... if they deny for not enough proof of weight than you just wait it out another 6 months to a year.

If the approve then score for you...

Just be careful to not use an appeal if you try to use this year... very often you only get 2 formal appeals. If you know your pushing the qualification limits. Its better to get the denial... know exactly what the now want and do those things.

Good Luck

~SARA
~m

I agree with Sara.  It's not going to hurt to submit, the worst that can happen is you get denied.  And trust me, it seems devastating (because I was denied at first)  but it's not the end of the world.  One good thing about a denial (if you can look at it in this way!) is they will spell it out for you exactly what you are missing or why you are being denied.  Then, you complete the requirements as spelled out in their denial and you know you have competed what they are asking for.

I was worried about the same thing the OP was writing about.  I too didn't know if I had 2 years weight 'history' because who wants to go to the dr when their fat...right??  I had a weight in Aug 2007 and then again in Sept 2008.  My surgery is in 17 days.  

They didn't require me to wait until Aug 2009 when the two years was up....I had 2 year (2007 & 2008) of documented obesity.  

If it were me, I'd submit and hope for the best.  Make sure all you other documentation is complete....6 months of supervised dieting with your PCP .  I did talk to someone at aetna and they offer the 3 month multidisciplinary program (what I did) or the 6 month dr supervised diet.  He told me Aetna goes on DAYS, not months, so this really means 90 days or 180 days.   They will deny if you haven't seen your PCP for 180 days, for example.

Good Luck to you!!